Inspection·March 10, 2023

F 0656 Level of Harm - Potential for minimal harm Residents Affected - Many for 3/2023 documented in part: Advance directives - FULL CODE. No care plan was found for advance directives both on paper and in the electronic health record. At 11:58 AM R134's health record documented that R134's admission date was on [DATE] with diagnoses not limited to chronic obstructive pulmonary disease, convulsions, type 2 diabetes mellitus, hypercholesterolemia, benign prostatic hyperplasia, spinal stenosis, schizoaffective disorder, hypertension, and polyosteoarthritis. R134's POS for 3/2023 documented in part: Advance directives - FULL CODE. Surveyor was unable to find existing care plan for Advance directives both on paper and in the electronic health record. At 12:05 PM V22 (Social Service Director) was interviewed and stated that she has been working in the facility for 15 years. V22 stated that currently there are 3 Social Services (SS) in the facility. V22 stated that SS is responsible in doing care plan for residents that focuses on cognition, communication, mood, psychosocial needs, behavior and discharge planning. V22 stated that the care plan for every resident can be found in electronic health record. V22 stated that care plans are being printed by Interdisciplinary Team and kept in resident's chart. V22 stated that the nurse will get an order for the code status of each resident and will be reflected in the Physician Order Sheet (POS) under Advance directives. V22 stated that Advance directives are being reviewed on a regular basis - quarterly, annually and with significant changes during care plan meeting or as needed. V22 stated that they are not doing care plan for code status or Advance directives. V22 stated that advance directives or code status is only included in SS notes and POS. V22 is not aware that Advance directives should have a care plan. Electronic health record reviewed with V22 for R90, R103, R52, R22, R85, R134 with no care plan found for advance directives. At 12:37 PM V3 (Director of Nursing/DON) was interviewed and stated that Interdisciplinary Team is responsible in doing the care plan for each resident. V3 stated I think Advance directives care plan is being done by Social Services. Surveyor informed V3 that Social Service Director is not aware that advance directives care plan should be done. V3 stated, I will ask our care plan coordinator. At 3:05pm V32 (Registered Nurse/RN/MDS/Minimum Data Set/CP/Care Plan Coordinator) was interviewed and stated that upon admission resident should have a baseline care plan. V32 stated that comprehensive care plan is completed within 14 days of admission and reviewed every quarter or as needed. V32 stated that care plan should be individualized and completed by Interdisciplinary Team (IDT). V32 stated that Advance directives care plan are not done for all residents. (V32) further stated there are no existing care plan for Advance directives. V32 stated that she started doing care plan as of today ([DATE]) for residents with DNR code status. V32 stated that the purpose of care plan is to identify problems/concerns of resident, establish goals and add necessary interventions to address the problems. V32 stated that care plan serves as a communication tool and a guide for staff on how to take care the resident. V32 stated that the potential effect of not having a care plan is that staff will not have a guidance to address the problem and to carry out interventions. Review of facility's census dated [DATE] indicated 144 residents with 2 bed holds, total census was 142 residents. Facility Care Plan policy, dated [DATE], documented in part: A written, individualized plan of care will be completed by the Interdisciplinary Care Team within (14) days of admission and revised every (90) days or more frequently if a change of status and/or condition warrants an interim review and update. 1. To promote high quality care. 2. To identify areas of concern and to establish guidelines for effective prevention/treatment of same through identifying problems, setting goals, and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145796 If continuation sheet Page 2 of 16 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145796 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Balmoral Home 2055 West Balmoral Avenue Chicago, IL 60625 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Potential for minimal harm agreeing on approaches to reach the goals. 3. To provide an avenue for discussion/teaching resident and family members regarding goals and interventions being utilized for achieving residents' well being. 4. To provide guidelines for documentation necessary to indicate care being offered to each resident. 6. To promote compliance with facility policy and procedures, state and federal requirements. Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145796 If continuation sheet Page 3 of 16 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145796 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Balmoral Home 2055 West Balmoral Avenue Chicago, IL 60625 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** A.2. On 03/07/23 at 11:00 AM R12 was observed lying in bed in a low fowler's position in a low bed with a low air loss mattress and floor mats. Residents Affected - Few On 03/08/23 at 11:49 AM R12 was observed in bed in a semi-Fowler's position leaning to the right side with a meal tray on the overbed table containing juice, a straw, pepper steak, vegetables and rice. R12 stated, I don't want to eat that. I want some cottage cheese and can you let my head down. Surveyor responded, I will go get your nurse. Surveyor exited room to let R12's nurse know R12's request. On 03/08/23 at 11:51 AM V25 (Agency Licensed Practical Nurse) was asked by the surveyor to assist R12. V25 stated, I will go in there and check on R12. V25 entered R12's room with V26 (Agency Certified Nurse Assistant). V26 lowered the head of R12's bed then exited R12's room and returned with cottage cheese in a small white styrofoam cup. R12 was observed eating cottage cheese from a small white styrofoam cup while lying in a low fowler's position. R12 was observe to cough while consuming the cottage cheese. On 03/08/23 at 11:58 AM surveyor requested that V25 (Agency Licensed Practical Nurse) observe R12's positioning in the bed. V25 stated, V26 (Agency Certified Nurse Assistant) let R12's head of the bed down. R12's head is at least 35-40 degrees. I guess there is a potential for aspiration, but it all depends. We can always adjust R12's head up. V25 entered R12's room and elevated the head of the bed then stated, R12's head of the bed is upright, almost at a 90-degree angle but not a complete 90-degrees. On 03/08/23 at 12:04 PM surveyor asked V3 (Director of Nursing) to observe R12's position in bed. V3 stated, R12 is almost at a 90-degree angle, at about 70-80-degrees. It is a possibility for aspiration. On 03/08/23 at 02:17 PM V26 (Agency Certified Nurse Assistant) stated, Initially when I entered R12's room R12 was leaning toward the wall. I straightened R12 in bed. I was not sure if R12 was a feeder. R12 said that she (R12) could feed herself and did not want to be fed. I did let R12's head of the bed down and I took R12 the cottage cheese. R12 does not like sitting up. On 03/09/23 at 09:37 V1 (Administrator) stated, We do not have a current speech evaluation for R12. On 03/09/23 at 10:27 V33 (Contracted Speech Language Pathologist) stated, I do not see R12. We have been here since January 2021. R12 has never been seen by speech and the facility have never sent a referral or anything. If a resident is not positioned in the upright position as much as they can be, they can cough and choke. The goal is to decrease any potential of aspiration. Nutritional Risk Review (Dietary) dated 01/23/23 documents in part: readmission: [DATE] Appetite is good to variable but needs assistance with meals. At risk of malnutrition d/t recent hospitalization, Monitor weight and intake. Care Plan documents in part: Swallowing problems/Dysphagia. R12 has a history of Dysphagia (per Hospital ST/Speech Therapist Bedside Swallow Eval/Evaluation -11/28/16) and at risk to potentially choke or aspirate food or liquids. 10/29/20 Resident should be positioned prior to oral intake. Resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145796 If continuation sheet Page 4 of 16 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145796 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Balmoral Home 2055 West Balmoral Avenue Chicago, IL 60625 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few was referred to ST (Speech Therapy) during this assessment period of 10/30/2020 d/t coughing while taking her medications. 04/01/21 Added to Feeder. Intervention: Follow Speech therapist recommendations (as ordered) such as: Sit at 90 degree angle, no straw, small bits and sips, alternate solids & liquids, slow rate of food presentation *Instruct and remind resident to eat in an upright position, to eat slowly, and to chew each bite thoroughly. *Sit at 90-degree angle, no straw, small bits and sips, alternate solids and liquids, slow rate food presentation. Date initiated 10/24/18. Facility Aspiration Precautions policy (undated) documents in part: Aspiration is a common problem among the residents who have difficulty swallowing or dysphagia. Signs of aspiration: cough before or after swallowing. Procedure: 2. After an assessment of the aspiration is completed a plan of care is developed to minimize the risk of aspiration, interventions that may include in the plan include but are not limited to: elevation of the head of the bed. B.1. On 3/08/2023 at 10:50 AM, medication administration observation conducted with V16 (Registered Nurse). At 10:58 AM, after V16 checked R1's blood glucose with a glucometer device. V16 disinfected glucometer device with a bleach wipe and left it wrapped around with the same bleach wipe. At 11:01 AM, V16 removed the bleach wipe that was wrapped around the glucometer device and took a piece of dry tissue paper to wipe the visibly wet glucometer device. At 11:03 AM, V16 checked R110's blood glucose with the same glucometer device and right after, V16 disinfected the device with a bleach wipe and left it wrapped around the same bleach wipe and placed it inside a clear cup. At 11:14 AM, V16 entered R143's room to check R143's blood glucose with the same glucometer device. V16 removed the bleach wipe that was wrapped around the glucometer device. Surveyor observed that the device was still visibly wet. V16 took a piece of dry tissue paper on the medication cart and wiped the wet glucometer device. On 3/09/23 at 9:40 AM, during interview V2 (Director of Nursing) stated that nurses should be disinfecting the glucometer device with a bleach wipe in between each resident's use. V2 stated that the purpose of disinfecting is to kill the bacteria and to prevent cross contaminations with the residents. V2 stated that the correct way of disinfecting the glucometer device is to clean with one wipe then throw away and then cover and wrap the device with a new wipe for 3 minutes, and then air dry for 1 minute before using with the resident. V2 stated that the wet device should be air dried and is not supposed to be wiped with a dry tissue paper. The facility's bleach wipe directions for use indicates that a 30 second contact time is required to kill the bacteria and viruses except a 1 minute contact time is required to kill Candida albicans and Trichophyton interdigitale, and a 3 minute contact time is required to kill Clostridium difficile spores. Reapply as necessary to ensure that the surface remains visibly wet for the entire contact time. Allow surface to air dry and discard used wipe. Facility Glucometer Infection Control Policy, revised on 1/1/2021, reads in part: OBJECTIVE: To prevent the spread of blood borne pathogen from patient to patient or patient to health care worker while performing blood glucose monitoring. POLICY: 4. While wearing gloves, the blood glucose monitor will be thoroughly cleaned and disinfected after each use with Bleach wipes. 5. The glucometer must be kept visibly wet for 3 minutes. Se additional wipes if needed to assure continuous 3 minutes wet contact time. 6. The blood glucose monitor will be placed to air dry on the nursing cart. B.2. On 03/07/23 at 11:56 AM, surveyor observed signage for Enhanced Barrier Precautions posted on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145796 If continuation sheet Page 5 of 16 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145796 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Balmoral Home 2055 West Balmoral Avenue Chicago, IL 60625 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 R122's bedroom door. Level of Harm - Minimal harm or potential for actual harm On 03/07/23 at 12:02 PM, surveyor observed V14 (Activity Aide) deliver R122's lunch tray in R122's room without doing hand hygiene before entering R122's room. Surveyor did not observe V14 washing hands in a sink or using hand sanitizer. Residents Affected - Few On 03/07/23 at 12:03 PM, surveyor observed V14 leave R122's room without performing hand hygiene. Surveyor did not observe V14 washing hands in a sink or using hand sanitizer. On 03/07/23 at 3:27 PM, V14 stated that V14 helps the nursing staff pass out resident meal trays and that V14 follows the directions on the signs posted on the resident's door regarding precautions. V14 stated, I put on PPE or do whatever the sign says to do. V14 stated that V14 follows the precautions posted outside a resident's room even if I'm only going in to drop off a meal tray. On 03/08/23 at 10:39 AM, V19 (Registered Nurse) stated that if a staff member was to enter into a resident's room with a Enhanced Barrier Precaution sign on the door and was providing direct care that staff would need to put on full PPE but if the staff is only going into the room (non-contact) the staff would only need to do hand sanitizing before entering the room and after leaving the room. V19 stated that the purpose of the hand sanitizer is to prevent cross contamination between the residents. On 03/08/23 at 4:53 PM, V3 (Director of Nursing) stated that the purpose of the Enhanced Barrier Precautions is to prevent cross contamination between residents and that all residents with wounds, or urinary catheters, feeding tubes or is receiving intravenous fluids are put on Enhanced Barrier Precautions. V3 stated that if a resident in on Enhanced Barrier Precautions then staff needs to do hand hygiene by either washing hands or using hand sanitizer before entering the resident's room and after leaving the resident's room. V3 stated that if the staff is providing direct care, then the staff would need to wear gloves and a gown. V3 stated that if a staff member is delivering a tray to a resident on Enhanced Barrier Precautions then the staff would need to perform hand hygiene before going into the room and after coming out of the room. R122's admission Record documented R122's diagnoses include but are not limited to cognitive communication deficit, mild neurocognitive disorder, feeding difficulties, gastrostomy status, respiratory failure, asthma, diaphragm hernia, pulmonary embolism, schizoaffective disorder - bipolar type, amnesia, hypertension, need for assistance with personal care, osteoarthritis, muscle weakness, unsteadiness on feet, lack of coordination, stiffness of unspecified joint, and abnormal posture. R122's MDS (Minimum Data Set) signed on 02/07/23 BIMS (Brief Interview for Mental Status) score is 04 indicating severe cognitive impairment. R122's Physician Orders dated 02/28/23 document in part, tube feedings at 60 ml per hour for 21 hours or a total of 1260 ml per day. R122's Physician Orders dated 03/01/23 documents, On enhanced barrier precautions. R122's care plan initiated 03/07/23 documents in part R122 is on enhanced barrier precaution due to J-Tube placement and staff are to clean their hands including before entering and leaving the room. Facility Enhanced Barrier Precaution (EBP) policy dated 11/02/22 documents in part that EBP (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145796 If continuation sheet Page 6 of 16 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145796 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Balmoral Home 2055 West Balmoral Avenue Chicago, IL 60625 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Level of Harm - Minimal harm or potential for actual harm indicated for residents with indwelling medical devices which include but are not limited to feeding tubes and hand hygiene required every time. Enhanced Barrier Precaution sign from a government agency documents in part, everyone must clean their hands, including before entering and when leaving the room. Residents Affected - Few Failures resulted in two deficient practice statements. A. Based on observation, interview, and record review, the facility failed to follow their Aspiration Precautions policy and follow speech therapy recommendations for 2 (R12 and R66) of 29 residents reviewed for improper nursing care. B. Based on observation, interview, and record review, the facility failed to follow policy and procedure on glucometer cleaning to prevent cross contamination for 2 (R110, R143) of 3 residents observed for blood glucose monitoring during medication administration. The facility also failed to follow its Enhanced Barrier Precautions policy for one resident (R122) by not sanitizing hands prior to and after entering resident's room. Findings include: A.1. R66's diagnoses include but not limited to abnormal posture, gastro-esophageal reflux disease, and dysphagia. R66's Physician Orders include orders for STRICT ASPIRATION PRECAUTIONS and FEED SLOW, NO STRAWS. R66's Nutritional Risk Review assessment dated [DATE] documents in part that R66 requires extensive assistance with eating and requires one-person physical assist. R66's comprehensive care plan includes a focus initiated on 04/01/2022 that documents in part: SWALLOWING PROBLEMS - MODERATE - SEVERE ORAL DYSPHAGIA: [R66] demonstrates some risk to potentially choke or aspirate food or liquids. One of the interventions initiated on 06/18/2019 documents in part: Follow Speech Therapist recommendations: Sit at 90-degree angle, no straw, small bites and sips, alternate solids & liquids, slow rate of food presentation. On 03/08/2023 at 09:43 AM, surveyor observed R66 lying in bed in semi-Fowler's position (approximately 30-degrees). R66 was slumped down in bed on [R66's] right side. R66 was holding a 6-ounce cup with a straw. R66 took a sip and started coughing. No staff was observed at bedside. On 03/08/2023 at 09:45 AM, V14 (Activity Aide) was pushing a snack cart and passing out juices and coffee to residents. V14 stated [V14] gave R66 a cup of coffee for after breakfast refreshment. On 03/08/2023 at 09:55 AM, surveyor also observed a large pink jug with a straw on top of a dresser across R66's foot of the bed. Surveyor asked if the pink jug belonged to R66. [R66] nodded 'yes.' On 03/08/2023 at 09:56 AM, V15 (Agency Certified Nurse Aide) stated it was [V15's] first day taking care of R66. V15 stated [V15] did not know if R66 is allowed to drink with straws. V15 stated [V15] needed to ask the facility's Certified Nurse Aide who usually takes care of R66 or the nurse in charge of R66. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145796 If continuation sheet Page 7 of 16 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145796 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Balmoral Home 2055 West Balmoral Avenue Chicago, IL 60625 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Level of Harm - Minimal harm or potential for actual harm On 03/08/2023 at 10:06 AM, surveyor overheard V16 (Nurse) arranging for a swallow evaluation appointment for R66. V16 stated R66 has a diagnosis of dysphagia, and the physician wants a re-evaluation to see if R66 can safely transition to a different diet. When asked whether R66 can use a straw for drinking, V16 stated R66 can use a straw. V16 grabbed the paper chart to verify orders but was distracted and did not see the order for NO STRAWS. Residents Affected - Few On 03/09/2023 at 10:29 AM, V33 (Speech Pathologist) stated this morning was the first time V33 evaluated R66. V33 stated R66 requires one-to-one feeding assist which is the level of assist needed during mealtimes and liquid intake as well. V33 stated R66 can feed self but should not be left alone with food or drinks due to cognitive or functional reasons. V33 stated staff should remain with R66 throughout the entire time. When asked regarding R66's 'NO STRAWS' order, V33 stated that was the order at the time prior to [V33's] evaluation. After evaluation, V33 stated R66 can use a straw but with one-to-one supervision. V33 also stated that staff should sit R66 in the upright position, approximately 90 degrees. V33 stated if R66 is not at upright position, then R66 can cough or choke because food is not going down by natural gravity. V33 stated the biggest thing is the potential for aspiration. When informed of surveyor's observations on 03/08/2023 at 09:43 AM, V33 stated [R66] should have been upright with staff watching [R66] drink the coffee. Facility's Aspiration Precautions policy dated 01/01/2020 documents in part: Aspiration is a common problem among the residents who have difficulty swallowing or dysphagia. Aspiration means a food or fluids that should go into the stomach go into the lungs instead. When such material goes into the lungs it can cause Aspiration Pneumonia .Signs of aspiration include cough before or after swallowing. Interventions to minimize the risk of aspiration include elevation of the head of the bed and special swallowing and feeding strategies. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145796 If continuation sheet Page 8 of 16 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145796 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Balmoral Home 2055 West Balmoral Avenue Chicago, IL 60625 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure low air loss mattress devices were properly working and on the correct setting for 2 (R11, R146) of 2 residents identified as at risk for developing pressure ulcers in a sample of 29 residents reviewed for skin preventative measures. Residents Affected - Few Findings include: 1. On 3/07/23 at 2:15 PM, R146 was lying in bed alert but confused. R146's low air loss mattress was deflated, and the device was unplugged. At 2:17 PM, surveyor entered R146's room with V31 (Registered Nurse) and stated R146 had pressure ulcers on R146's sacrum that were healed and should have the low air loss mattress for preventative measures. V31 stated that the low air loss mattress machine should be on when R146 is in bed. At 2:20 PM, during interview V31 stated that bedridden residents who are at risk for developing pressure ulcers should have the low air loss mattress to prevent them from developing pressure ulcers. V31 stated that the correct setting should be based on the resident's weight and should be turned on when the resident is in bed. V31 stated that if the settings are incorrect and if the machine is off, it would not help the resident in preventing pressure ulcer development. On 3/09/23 at 9:40 AM, during interview V2 (Director of Nursing) stated that residents who are at risk for developing pressure ulcers should have the low air loss mattress for prevention. V2 stated that the low air loss mattress should be on at all times and on the correct setting to benefit the resident while in bed. V2 stated that if it's not on the correct setting and if it's not properly working, It could put more pressure on the resident which is not good. V2 stated the setting should depend on the resident's weight. R146's clinical records show an admission date of 1/16/23 with listed diagnoses not limited to Alzheimer's Disease, Diabetes Mellitus, and Hypertension. R146's admission Minimum Data Set (MDS) with assessment reference date (ARD) of 2/7/23 shows R146 is cognitively impaired and is totally dependent with one staff assistance on bed mobility. It also shows that R146 is at risk for developing pressure ulcers/injuries. R146's skin care plan reads in part, The resident has potential for impairment to skin integrity r/t noted with redness on buttocks upon re-admission. Facility Pressure Ulcer Prevention Protocol policy (no date) reads in part: Procedures: 1. All residents will be assessed to determine their risk factor(s) for pressure ulcer development, upon admission and at least quarterly thereafter. 2. All beds in the facility will have pressure reducing mattresses unless pressure relieving mattresses are required according to the resident's needs. 4. Residents who are assessed as being at High Risk will have a plan of care that will include: C. Use of Pressure Reducing Devices, such as pressure reducing mattresses, mattress overlays, w/c cushioning devices, if needed. Facility Low Air Loss Mattress policy, dated 1/1/20, reads in part: Procedure: 6. At any time of a loss power, the resident will be removed from the low air loss mattress, or the mattress will be plugged into an emergency power source. 7. Follow the manufacturer's installation (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145796 If continuation sheet Page 9 of 16 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145796 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Balmoral Home 2055 West Balmoral Avenue Chicago, IL 60625 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 guideline and refer servicing to the Technical Customer Service. Level of Harm - Minimal harm or potential for actual harm 2. On 3/7/23 Surveyor observed R11 on a low air loss mattress overlay device dial set at 140. Residents Affected - Few On 3/7/23 at 12:50 PM, V31 (Registered Nurse) stated, The setting depends on the weight of the resident. Maintenance sets up the mattress. They ask the nurse what the resident's weight is. On 3/7/23 at 2:25PM, V17 (Licensed Practical Nurse) stated, It's an overlay; it serves as a low air loss mattress. It's set to 140. The purpose is to give comfort and avoid pressure ulcers. I'm not familiar with how it should be set. Maintenance sets it. On 3/8/23 Surveyor observed R11's low air loss mattress overlay device dial set at 140. R11's diagnoses include but are not limited to nondisplaced fracture of sixth cervical vertebra; Parkinson's disease; malignant neoplasm of prostate; pressure ulcer of sacral region, stage 4 (history); anemia, polyarthritis. Record review of R11's weights note R11's weight on 2/10/2023 at 11:08 was 208.4 pounds. R11's POS (Physician Order Summary) includes May use gel/air mattress. R11 is care planed for skin integrity. R11 has potential for skin tear/pressure related ulcer related to immobility, incontinent in both bowel and bladder, and need for assistance in turning self while in bed, with goal for R11 not to develop any skin ulcer. Interventions include apply and provide needs (e.g. pressure relieving mattress, pillows) to protect the skin while in bed, initiated 8/2019. MDS (Minimum Data Set) dated 1/20/23 documents R11 needs extensive assistance with two-person physical assist with bed mobility; is at risk of developing pressure ulcers/injuries; skin and ulcer/injury treatments include pressure reducing device for bed. Braden Scale for predicting pressure sore risk, dated 1/28/23, indicates R11 has a score of 11 meaning high risk. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145796 If continuation sheet Page 10 of 16 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145796 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Balmoral Home 2055 West Balmoral Avenue Chicago, IL 60625 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0688 Level of Harm - Minimal harm or potential for actual harm Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. 2. On 03/08/23 at 11:03 AM, surveyor observed R135 with bilateral hand contractures. R135 was not wearing any hand splints. R135 stated, My hands hurt me. Residents Affected - Few On 03/08/23 at 11:07 AM, V20 (Certified Nursing Assistant) stated that V20 had just finished bathing and changing R135. Surveyor asked V20 if R135 wears hand splints and V20 responded She doesn't wear hand splints. On 03/08/23 at 11:29 AM, V21 (Certified Occupational Therapist) stated that R135 wears hand splints in the form of a carrot splint for 1 or 2 hours three times per day. V21 stated that V21 works with R135 Monday-Friday and puts the hand splints on R135 during these daily sessions Monday-Friday. V21 stated that the staff is responsible for putting on and taking off the hand splints when V21 is not working with R135. V21 stated R135 should have a physician order for the hand splints so that the staff knows that R135 needs them and how often R135 should be wearing them. V21 stated that there are no therapy staff working at the facility on the weekends and that the nursing staff would know they needed to put R135's hand splints on based on the POS. V21 stated that the purpose of the hand splints is to preserve R135's finger movements, to prevent muscle and joint stiffness and more contractures. V21 stated that R135 already has contractures in R135's hands and that the hand splints are trying to prevent the contractures from getting worse. On 03/08/23 at 11:41 AM, after reviewing R135's POS in R135' medical chart V19 (Registered Nurse) stated, No, she does not have an order for hand splints. V19 stated that usually the nurses go by the treatment records instead of checking the physician order sheets for splint orders. On 03/08/23 at 11:42 AM, after reviewing R135's Treatment Administration Record for March 2023 V19 stated No, she does not have a treatment order for hand splints. V19 stated that usually the therapy staff put on R135's hand splints Monday - Friday and that the nursing staff would put the hand splints on the weekends and other times during the day on Monday-Friday. V19 stated that if the hand splints are not listed in the treatment record or physician order sheets then the nursing staff would not know that they had to put the hand splints on R135. V19 reviewed R135's previous physician order sheets from January and February and verbalized that bilateral hand splints were ordered on 01/04/23. V19 noted that someone discontinued the order to apply bilateral hand splints on the February 2023 Physician Orders however it was not signed or date. V19 stated, I don't know who or why someone did that. It was a mistake. V19 provided surveyor with copies of R135's Physician Orders for January 2023, February 2023, and March 2023 as well as copies of R135's Treatment Orders for January 2023, February 2023 and March 2023. On 03/09/23 at 11:49 AM, V27 (Restorative Aide/Staffing Coordinator) stated that the Occupational Therapist is the only one applying R135's hand splint and that the therapist would also put on R135's hand splints on the weekends. V27 stated that if therapy is not at the facility on the weekend, then no one would be providing the hand splints to R135. On 03/09/23 at 11:53 AM, V27 provided surveyor with altered Physician Order sheet from January 2023 with the new addition dated 01/31/23 which documented, Bilateral carrot inflatable brace applied during Occupational Therapy treatment. This is in comparison to the Physician Order Sheet from January 2023 provided to surveyor on 03/08/23 by V19 directly from R135's paper medical chart. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145796 If continuation sheet Page 11 of 16 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145796 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Balmoral Home 2055 West Balmoral Avenue Chicago, IL 60625 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0688 Level of Harm - Minimal harm or potential for actual harm R135's admission Record documented R135's diagnoses include but are not limited to cerebral infarction, muscle weakness, abnormal posture, need for assistance with personal care, dysphagia, hyperosmolality and hypernatremia, tachycardia, acute renal failure, anemia, atrial fibrillation, morbid (severe) obesity, glaucoma, type 2 diabetes mellitus, hyperlipidemia, hypertensive heart disease without heart failure, acquires absence of other right toes. Residents Affected - Few R135's MDS (Minimum Data Set) signed on 02/07/23 BIMS (Brief Interview for Mental Status) score is 15 indicating intact cognitive response. R135's Physician Orders dated 02/28/23 does not document treatment orders to apply bilateral hand splints. R135's Treatment Administration Record dated 03/2023 does not document treatment order to apply bilateral hand splints. R135's Physician Orders dated 01/04/23 documents in part, to apply bilateral hand splints. R135's Occupational Therapy Evaluation and Plan of Care dated 01/31/23 documents in part, R135 has severely impaired fine motor skills due to bilateral hand contractures and splint/orthotics recommended. R135's Care Plan dated 04/06/22, revised on 04/13/22 documents in part R135 with limited range of motion on both hands/fingers related to diagnosis of Cerebrovascular Accident and R135 wears left hand splint and carrot to right hand for 1 hour 2-3 times per day per Occupational Therapist recommendation. Based on observation, interview and record review, the facility failed to ensure adaptive devices were applied to residents' hands to prevent further contracture or deformities. This failure applies to 2 (R22, R35) residents out of 4 residents reviewed for limited range of motion in the final sample of 29 residents. Findings include: 1. On 3/7/23 10:59 AM R22 was observed lying on bed, head of bed elevated. R22 was observed with bed on lowest position and floor pads. R22 was observed alert but non-verbal, able to nod head. Surveyor observed R22's left hand contracted, fist closed with no adaptive device or splint. At 12:06 pm R22 was observed lying on bed, left hand fist closed with no adaptive device. Observed staff assisting R22 at lunchtime. On 3/8/23 at 12:18pm V23 (Restorative Nurse/Registered Nurse/RN) was interviewed and stated that she has been working in the facility for 2 years. V23 stated that residents are assessed for adaptive or assistive device upon admission, readmission, quarterly and significant changes. R22's electronic health record was reviewed with V23 and stated that R22 requires total assistance with activities of daily living. V23 stated that R22 uses a mechanical lift for transfer. V23 stated that R22 is currently on restorative programs for Passive Range of Motion (PROM) exercises. V23 stated that adaptive devices are applied and monitored by nursing staff on the floor. At 12:37pm V3 (Director of Nursing/DON) was interviewed and stated that adaptive devices should (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145796 If continuation sheet Page 12 of 16 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145796 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Balmoral Home 2055 West Balmoral Avenue Chicago, IL 60625 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few have an order in the Physician Order Sheet (POS) and reflected in Treatment Administration Record (TAR). V3 stated that the nurse on duty would inform assigned Certified Nurse Assistant (CNA) if there is any adaptive device ordered for resident. V3 stated that staff is expected to do rounding every 2 hours and as needed to check resident and adaptive devices are in place. V3 stated that R22 has on order of hand roll/cushion for left hand and should be applied at all times except care. Surveyor informed V3 that hand roll/cushion was not found during surveyor rounding on two occasions. V3 stated that she (V3) educated staff on how to apply the hand roll after lunchtime on 3/7/23. V3 stated that the potential effect of not applying hand roll to resident can cause progression of contractures/further deformities. Review of R22's health record documented that R22's admission date was on 1/1/21 with diagnoses not limited to cerebrovascular disease; hemiplegia and hemiparesis following unspecified cerebrovascular disease; chronic obstructive pulmonary disease; dysphagia; schizoaffective disorder, bipolar type; and unspecified convulsions. R22's POS for 3/2023 documented in part: Wear hand cushion on left hand at all times except during care with order date of 11/18/21. R22's care plan documented in part: Wear hand cushion on left hand at all times except during care, date initiated 11/18/21; revision date 3/9/23. Facility Splinting policy (no date) documented in part: Purpose - To prevent contractures or decreased tone and to protect joint alignment. II. A physician's order will be obtained for the use of a splint. III. A care plan must be completed with splinting schedule, application and/or positioning instructions and precautions for nursing staff as applicable. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145796 If continuation sheet Page 13 of 16 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145796 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Balmoral Home 2055 West Balmoral Avenue Chicago, IL 60625 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to follow smoking safety policy to provide a safe and healthy living environment with respect for the health and well-being needs of each resident, staff member and visitor. This failure applies to 1 (R85) resident who is on supervised smoking out of 5 residents reviewed for smoking in the final sample of 29 residents. Findings include: On 3/7/23 11:38 AM R85 was observed sitting in a high back wheelchair by his bedside tray table in his room. Surveyor observed a pack of cigarettes on the bedside tray table. R85 is alert and verbally responsive. R85 stated he is a smoker, and he keeps his own cigarettes and lighter. Survey team observed R85 in the 1st floor dining room in a wheelchair holding a pack of cigarettes in his right hand. On 3/8/23 at 12:05pm V22 (Social Service Director) was interviewed and stated that she has been working in the facility for 15 years. V22 stated that smoking assessment is being done upon admission and annually or as needed. V22 stated that if resident is non-compliant with smoking policy such as selling cigarettes to other residents, smoking in the building, smoking in non-designated areas, resident will be placed on smoking program or supervised smoking meaning that every time resident smokes will be supervised by staff. V22 stated that resident on smoking program or supervised smoking is not allowed to carry cigarettes and/or lighter. R85's electronic health record was reviewed with V22. V22 stated that R85 had an extensive/multiple history of non-compliance with smoking policy. V22 stated that R85's last noncompliance with smoking policy was on January 10, 2023. V22 stated that R85 is on smoking program or supervised smoking. V22 stated that R85 is not allowed to carry cigarettes and/or lighter. V22 was made aware by surveyor that a pack of cigarettes was observed at R85's tray table in his room. V22 was also informed that another survey team observed R85 holding a pack of cigarettes in his (R85) hand. R85's health record was reviewed and documented that R85's admission date was on 2/9/16 with diagnoses not limited to Alzheimer's disease, chronic obstructive pulmonary disease, anemia, schizoaffective disorder, arthropathy, convulsions, major depressive disorder, and diabetes mellitus type 2. Review of R85's smoking risk review assessment dated [DATE] documented in part: May not be capable of handling/carrying any smoking materials and requires supervision when smoking. Review of R85's psychosocial note dated 2/13/23 documented in part: Resident is also closely monitored for compliance with the smoking policy and he is unable to handle own smoking materials at this time. Resident continues to receive 1 cigarette per smoking break. Review of R85's care plan with revision date of 3/9/23 documented in part: The resident was noted with smoking non-compliance. Goal with target date of 5/24/23: The resident will comply with all rules and policies regulating smoking. The resident will demonstrate compliance with safe smoking policies as evidenced by not smoking in unauthorized areas. On 1/9/23 smoking materials were confiscated, and staff addressed smoking non-compliance. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145796 If continuation sheet Page 14 of 16 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145796 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Balmoral Home 2055 West Balmoral Avenue Chicago, IL 60625 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Facility Smoking Safety policy (no date) documented in part: To provide a safe and healthy living environment with respect for the health and well-being needs of each resident, staff member and visitor. 1. Smoking is only allowed in designated areas established by management. The designated area(s) will be outside in accordance with state / local standards. Supervised smoking rules: 1. The resident on supervised smoking are NOT permitted to have ANY smoking materials in their possession at any time. 3. Persons on supervised smoking may ONLY smoke with staff supervision at designated times. 5. Nursing staff/front desk staff and designated smoking monitoring staff is being informed on the ongoing basis of updated list of residents who are considered unsafe smokers. Event ID: Facility ID: 145796 If continuation sheet Page 15 of 16 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145796 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Balmoral Home 2055 West Balmoral Avenue Chicago, IL 60625 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview and record review the facility failed to ensure food trays were distributed in a sanitary manner to prevent contamination for 1 (R130) resident being served food on the first floor in a sample of 29. Findings Include: On 03/07/23 at 11:27 AM dietary staff were observed on the first floor with the steam table in hallway in front of the men's shower room serving food trays. On 03/07/23 at 11:34 AM V11 (Activity Aide) placed a used plate cover on the overbed table next to two pitchers of red juice. On 03/07/23 at 11:36 AM V9 (Agency Certified Nurse Assistant) removed the used plate cover that was placed on the overbed table by V11 (Activity Aide), placed the plate cover over R130's food then proceeded down the hallway and delivered the food tray to R130's room. V9 returned to the steam table. Surveyor asked V9 did she (V9) realize that the plate cover that she (V9) used to cover R130's plate was already used to cover and deliver a food tray to another resident. V9 stated, No I did not realize that the plate cover had already been used. There is a potential for cross contamination. On 03/07/23 at 12:23 PM V11 (Activity Aide) stated, I have worked here for 2 years. Surveyor asked V11 (Activity Aide) where are the used plate covers placed after serving the resident meal. V11 stated, I usually put the plate covers on the table or cart with the dirty trays after we serve. The plate cover that I put on the overbed table next to the pitchers of juice was a used one. A used plate cover can potentially contaminate the food on the next tray. On 03/09/23 at 10:43 AM V10 (Dietary Supervisor) stated, I have worked here for 19 years. The first-floor trays are served from the steam table in the hallway. Dietary staff serve the food, and the Certified Nurse Assistants pass the food to the resident. The plate cover lid is left with the resident when they are eating. The lid should be considered dirty and should be placed on the bottom of the cart somewhere where it is considered dirty. The dirty lid should not have been placed on the overbed table next to the juice, it should have been separate. By placing the plate cover over the other resident food there is a potential for infection and contamination. We will do an in service right away. Facility Policy and Procedures undated document in part: Purpose: These procedures will help prevent infection and contamination during tray service. 1. During meal service staff will deliver the tray to the resident's room and the plate cover should be left in the room. 2. If tray set up is needed the plate cover will be removed and will be left on the table side of the resident. 3. Soiled tray with cover will be removed from the room only during dirty trays collection. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145796 If continuation sheet Page 16 of 16